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Needs Improvement:  Wedding Day Imminent
from Rachel

Dear Ed:  I discovered FlakeHQ while surfing the web about a month ago.  I have mild plaque psoriasis with the worst patches occurring on my scalp, some nail psoriasis (thumb and big toe), and some stubborn small patches on my torso and underneath one of my breasts.  (I was diagnosed with P about 8 years ago — when I was 20 — and it has mostly waned except in the winter and periods of great stress). I recently fired one derm (she cancelled too many appointments, wrote me scrips without adequate explanation, kept me waiting two hours, etc.) and found a new one.  I should add, as an aside, that the reason for this was that my P was flaring (a word I just learned) at its worst ever and I am getting married in three months and am concerned about my P on my wedding day (a vanity I am allowing myself).

My new derm prescribed the following: Olux Foam for the scalp, which has worked thus far quite well.  I had tried DermaSmoothe before but really hate going to bed with an oily head covered by a shower cap, and my job/life don't allow me to apply and leave on for several hours unless I am asleep.  I am, however, slightly concerned about the rebound effect that might occur when I stop using the Olux.  But I think that the two shampoos (Nizoral/T-Gel on alternate days) are helping as well.

He also prescribed Dovonex applications in the morning with Ultravate at night.  As it happens my pharmacy was out of Ultravate and I had to wait before picking up the prescription so I used Dovonex exclusively for about four days, and noted huge improvement on my smallest lesions, some improvement on the others.  I noted, by the way (because I had recently read your Dovonex trial) that in the prescribing info it recommends Dovonex only for mild to moderate P.  I wonder if that is because the larger the lesion, the less effective it is?

When I used the Ultravate for the first time I noticed that my skin had bleached the following morning at the area where I had used it.  Do you have any idea why that might be?  It concerns me for obvious reasons (keep in mind that I am not dark skinned at all, rather am of Eastern European Jewish descent so am as pale as they come and my skin still looked even paler).

Finally he prescribed Elidel (a non-steroidal cream) for the region under my breast.  This seems to be working, but I need some more time to know for sure on that.  I had tried Dovonex under the breast years and years ago (when Dovonex was first released) but it made the skin crack and bleed (not a fun situation when wearing a bra).  I realize that you are not female, but perhaps you could point me in the direction of how other women have dealt with this problem?

Sorry for rambling at length, it is simply that yours is the first site I have found that has answered any questions I have had (other than NPF’s site[ ]) and I know no psoriatics to interrogate.  Thanks for all you do.  –Rachel

*****

Ed’s Response:  First, congratulations on your upcoming wedding, Rachel.  Nobody wants to be flaming upon that occasion, so I hope by then your crisis will have passed.. 

Your question about Dovonex perhaps not working as well on larger lesions is a good one.  You’re right about the fact that when I tried Dovonex and wrote about it I was worse than moderate, and Dovonex is recommended for mild to moderate P.  I’d never thought about lesion size, but in some respects it makes sense that any topical medication is likely to have a harder time working on larger lesions.  Larger lesions — on me at least — tend to be thicker lesions, too.  A lesion is “thick” for two reasons: one, inflammation swells certain layers of the dermis; and two, the top layers of skin die off many times faster than normal forming the flakes or crusts that are typical of plaque P.  These flakes and crusts can’t benefit from the topical medication, so the medication must penetrate through them to get to the living tissue that can be helped.  This penetration business is a time-limited phenomenon, as it pretty much must occur before the base (the oil, cream, or ointment carrying the medicine) evaporates or gets rubbed off.  This means less of it is going to get through the thick flakes or crust of a large lesion. 

I’ve been hearing nothing but good things about the Dovonex/Ultravate combo therapy.  I’m going to be starting it myself day after tomorrow.  My derm instructed me to mix equal parts of the two in the palm of my hand and apply them together.  I’m wondering if this is effectively any different than the one-in-the-morning, other-at-night regimen your derm prescribed? 

I will be very happy if my lesions, too, have waned by the time you get married!

With regard to OTC shampoos.  I never had much luck with Nizoral and, before methotrexate finally calmed my scalp P, I considered T-Gel second best to Pentrax.  Pentrax, which I believe is manufactured in Canada, was difficult for me to keep stocked; so, more often than not, I had to make do with the T-Gel.  Some years into my worst scalp P, Neutrogena came out with T-Gel Extra Strength.  Still not as potent as Pentrax (less percentage of coal tar derivative), it did much better than the original T-Gel.  It worked so well, in fact, that I stopped fuming about my inability to find Pentrax.  Today I use regular T-Gel as my daily shampoo.  (This is probably overkill, but I’m used to it and I don’t EVER want to see my scalp P again.)  If an errant itch happens, or there is any other slightest suggestion that a lesion might be re-activating up there, I switch to T-Gel Extra Strength for a few days.  So far, knock on wood, the scalp P has remained at bay. 

Has your derm ever suggested the P under your breasts may be “flexural” P?  This is also called inverse psoriasis.  It tends to look like patches of red, inflamed skin, but without the prominent thickening or scale build-up.  My flexural P (groin area) itches the worst and causes the most pain (I guess Jockey shorts are about as friendly to flexural P as brassieres are to whatever kind it is you have under your breasts).  I use a very mild corticosteroid cream — Westcort — on my flexural and, usually, after a few days of application, it abates. 

Good luck and stay in touch.  We won’t expect to hear from you until after the honeymoon — which I’m confident won’t be hampered in the slightest by your P.  -Ed

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